Everything You Wanted to Know About Urologic Emergencies But Were Too Afraid to Ask Rachelle Rodriguez MS, APRN, AOCNP APP Supervisor – GU Oncology Inpatient Surgical APP – GU Oncology

OBJECTIVES 1) Identify Urologic Emergencies as they relate to our patient population at Moffitt Cancer Center. 2) Distinguish between Inpatient and Outpatient Urologic Referrals. 3) Develop a basic understanding of management of hydronephrosis, hematuria and urinary retention.

Lower Urinary Tract Obstruction Also referred to as Acute Urinary Retention (AUR)

Most common urologic emergency

Symptoms include: - Suprapubic pressure/dullness

- Lower abdominal discomfort/pain

- Inability to pass urine

More common in men

Incidence increases with age

Chronic urinary retention is typically not associated with any pain

3

Lower Urinary Tract Obstruction

4

Lower Urinary Tract Obstruction

5

Lower Urinary Tract Obstruction Diagnosis

• History • Bladder Scan • Bladder Ultrasound • Catheterization

Inpatient vs. Outpatient • Sepsis • Malignant Obstruction • Acute Myelopathy • Acute Renal Failure

Post Obstructive Diuresis

6

Urinary Retention Catheterization

• Difficulty with placement • Coude catheters • Contact urology for assistance with placement • Straight catheter versus indwelling catheter

Voiding Trial • Duration of catheter • High volume retention • Bladder scan post void to determine adequate emptying • Bladder scan for bladder distention, pressure pain

7

Urinary Retention Failed Void Trial

• Clean intermittent catheterization versus indwelling catheter replacement • Outpatient referral • Enlarged Prostate

• Medications • Prostate Artery Embolization (PAE) • Transurethral resection of the prostate

• Urology at MCC does not see patients for urinary retention in clinic

Clean Intermittent Catheterization (CIC) • Preferred Approach • Should be performed every 4-6 hours

8

Types of Catheters Standard

• Standard kits on floors 16 French and 18 French • Straight tip • Placement at Moffitt

Coude • Bent/Angled tip • Enlarged prostate • Placement at Moffitt

Three-Way Catheter • Catheter has an extra port for irrigation tubing • Used to run continuous bladder irrigation • Manual irrigation • Placement at Moffitt

9

Upper Urinary Tract Obstruction/Hydronephrosis

Hydronephrosis is defined as dilation of the pelvis

and calyces of one or both kidneys. This may result from obstruction to the flow of urine, vesicoureteral reflux, or it may be a primary

congenital deformity without an apparent cause.

10

Upper Urinary Tract Obstruction/Hydronephrosis Mechanical Obstruction

• Changes inside the urinary tract • Changes outside the urinary tract

Symptomatic • Renal colic • Flank pain/pressure • Costovertebral tenderness

Asymptomatic • Incidental finding on imaging • Normal renal function • No pain or discomfort

11

Upper Urinary Tract Obstruction/Hydronephrosis Diagnosis

• Normal renal function – preferred imaging CT Urogram • Elevated creatinine

• CT A/P without contrast • Renal/Bladder Ultrasound

Treatment • Foley catheter • Ureteral stent • Percutaneous Nephrostomy Tube

Complete or prolonged obstruction can lead to tubular atrophy and eventually irreversible renal injury

12

Pyelonephritis Symptoms

• Renal colic • Fever • Chills • Dysuria • Costovertebral tenderness

Diagnostic work up • CBC w/diff, BMP, Urinalysis, Urine Culture, Blood Culture • GU Imaging – CT A/P without contrast or CT Stone Protocol

Treatment • Obstructive pyelonephritis requires urgent decompression of obstructed kidney • No obstruction – medical management

13

Ureteral/Renal Stone CT Stone Protocol

UA w/microscopic analysis

Urine culture

Lab studies

AUA Guidelines • Less than or equal to 10mm - outpatient observation • Distal stones – medical expulsive therapy (MET)

Obstructive pyelonephritis requires urgent decompression of obstructed kidney

Stent pain/colic

Stent failure

14

Hematuria – Microscopic Asymptomatic microhematuria (AMH) is defined as three or greater red blood cells (RBC) per high powered field (HPF) on a properly collected urinary specimen and is not visible to the naked eye.

OUTPATIENT Work Up • Imaging of upper urinary tract (CT Urogram is imaging of choice) • Outpatient Cystoscopy

Risk factors for malignancy in patients with microscopic hematuria • Older age • Male gender • History of cigarette smoking • History of chemical exposure (cyclophosphamide, benzenes, aromatic amines) • History of pelvic radiation • Irritative voiding symptoms (urgency, frequency, dysuria) • Prior urologic disease or treatment • History of chronic indwelling catheters • History of recurrent UTIs

15

Hematuria – Gross Gross hematuria is visible to the naked eye

Urologic causes: • Renal tumors (benign or malignant) • Bladder tumors • Prostate cancer • Prostatic enlargement • Renal or ureteral stones • Trauma • Urinary tract infections

Medical causes: • Nephritis • Anticoagulation • Inflammatory conditions

16

Hematuria – Gross Management depends on additional factors

Is patient in retention? • Perform post void residual to determine if patient is emptying bladder • If in retention consult Urology for further assessment and/or catheter recommendations • Will likely require large, hematuria catheter • May require three way catheter for continuous bladder irrigation

Is patient transfusion dependent?

Does patient have UTI? • Ensure UA/Urine culture sent

Does urine clear with hydration? • Establish history of symptoms with patient • IV hydration

17

Hematuria – Cystitis Contributing Factors

• Ifosfamide • High-dose cyclophosphamide • Pelvic radiation • Hematopoietic stem cell transplant • Intravesical instillation of BCG

Signs and Symptoms • Mild hematuria • Bladder irritation • Gross hematuria • Clot Hematuria • Lower urinary tract symptoms (LUTS) • Suprapubic discomfort

18

Hematuria – Cystitis Diagnostics • Work up will ultimately depend on clinical evaluation

• Not all work up will be completed inpatient, if needed may include • Urine culture • Urine cytology • Viral urine studies • Upper urinary tract imaging • Cystoscopy

Interventions • Hydration • Catheter if indicated • Continuous bladder irrigation

19

BK Cystitis Hemorrhagic cystitis (HC) is a frequent complication after HSCT

Primary risk factor for late onset HC is infection by BK virus

Diagnosis: • Clinical symptoms of cystitis – dysuria, increased urinary frequency, lower abdominal pain • Macrohematuria • BK viremia with viral loads of >7 log10 copies/mL

Severity • Based upon severity of hematuria • Grade 1-4

Recommend ID Consult • Cidofovir • IV or Intravesical administration • Limited research

20

Fournier’s Gangrene Life threatening, necrotizing infection of the male or female perineum

Risk Factors • Older men • Diabetes • Obesity • AIDS • Malignancy • Alcoholism • Smoking • Renal failure • Colorectal cancer

21

Copyrights apply

Fournier’s Gangrene Local Symptoms Systemic Symptoms - Blisters - Hypotension -

- Bullae - Fever

- Edema - Tachycardia

- Subcutaneous gas - Shock

- Crepitus

Treatment • Broad spectrum antibiotics • Extensive surgical debridement and drainage • Hyperbaric oxygen treatment to reduce amount of debridement • Vacuum assisted closure devices

23

Additional Urologic Emergencies Priapism Persistent penile erection that continues hours beyond or is unrelated to sexual stimulation and lasting for at least 4 hours

Penile Fracture Occurs when the erect penis is forcibly bent, causing a rupture of the tunica albuginea of the corporal bodies of the penis

Testicular Torsion Testicular torsion results from inadequate fixation of the lower pole of the testis to the tunica vaginalis. If fixation is absent or insufficiently broad-based, the testis may twist on the spermatic cord, potentially producing ischemia from reduced arterial inflow and venous outflow obstruction.

24

Additional Urologic Emergencies Phimosis

• Abnormal constriction of the opening in the foreskin that precludes retraction over the glans penis, results from chronic inflammation and edema of the foreskin.

• Development of a phimosis often complicates sexual function, voiding, and hygiene. If the patient or medical staff forcibly retracts the foreskin, a paraphimosis (trapping of the foreskin) can occur.

Paraphimosis • Emergent urologic condition in which the foreskin of an uncircumcised or partially circumcised

male becomes retracted behind the coronal sulcus of the glans penis and will not return to its normal position.

• Untreated this can result in local skin necrosis, infarction, gangrene and autoamputation of the glans

25

Copyrights apply

Copyrights apply

Questions?

28

Claiming credit online is easy. Todays Event ID is: 348824

This code is only good for 5 days past the program

Click on link from your computer screen.

https://health.usf.edu/cpd

29

Use your cell phone Open your cell phone camera and hover your phone above the barcode below.

Or use a QR Reader app scan the barcode.

For questions and log in issues email cpdrss@usf.edu

References Barocas, D., Boorjian, S., Alvarez, R., Downs, T., Gross, C., Hamilton, B., . . . Souter, L. (2020). Microhematuria: AUA/SUFU Guideline. Retrieved September 07, 2020, from https://www.auanet.org/guidelines/microhematuria

Barrisford, GW, Steele, GS. Acute Urinary Retention. In: UpToDate, Post, O’Leary MP, Hockberger RS, (Ed), UpToDate, Waltham, MA, 2020.

Belyayeva M, Jeong JM. Acute Pyelonephritis. [Updated 2020 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519537/

Cesaro S. Haemorrhagic Cystitis and Renal Dysfunction. In: Carreras E, Dufour C, Mohty M, et al., editors. The EBMT Handbook: Hematopoietic Stem Cell Transplantation and Cellular Therapies [Internet]. 7th edition. Cham (CH): Springer; 2019. Chapter 51. Available from: https://www.ncbi.nlm.nih.gov/books/NBK553924/ doi: 10.1007/978-3-030-02278-5_51

Hy, D, Lee, BC, Choi, JB, Park, YM, Jung, HJ, Jae Jo, H. Fournier’s Gangrene in a Rectal Cancer Patient, International Journal of Surgery Case Reports, (67) 2020. https://doi.org/10.1016/j.ijscr.2020.01.040.

(http://www.sciencedirect.com/science/article/pii/S2210261220300547)

Linder, BJ, Chao, NJ, MM Gounder. Hemorrhagic Cystitis in Cancer Patients. In: UpToDate, Post, Drews RE, Schild, SE (Ed), UpToDate, Waltham, MA, 2020.

Zeidel, ML, O’Neill, WC. Clinical Manifestations and Diagnosis of Urinary tract Obstruction and Hydronephrosis. In: UpToDate, Post, Curhan, GC (Ed), UpToDate, Waltham, MA, 2020. 30